Healthcare Provider Details

I. General information

NPI: 1558473058
Provider Name (Legal Business Name): GARY WAYNE BOWMAN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 11/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55A S BROADVIEW
GREENBRIER AR
72058
US

IV. Provider business mailing address

PO BOX 596
GREENBRIER AR
72058
US

V. Phone/Fax

Practice location:
  • Phone: 501-679-4030
  • Fax: 501-679-4037
Mailing address:
  • Phone: 501-679-4030
  • Fax: 501-679-4037

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR4093
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: